Abortion care services continue to be stonewalled by some of the web’s most visited sites, as these Internet giants charge that abortion is not a family friendly topic.

The refusal to use abortion-related ads continues even as providers push to remove the stigma from the procedure with unapologetic online advertisements.

About half of women in the United States will have an unintended pregnancy by the age of 45, and almost a third of those pregnancies will end in abortion, a procedure that’s far safer than childbirth.

Only 40 percent of Americans say they spoke to someone else about their abortion experience, according to a recent Vox survey.

But those who’ve had abortions aren’t the only people who won’t use the A-word. In May, RH Reality Checkreported on a series of abortion-related video advertisements that were rejected by Google and Hulu on the grounds that the topic is “non family safe” and unsuitable for the millions of people who view the companies’ websites.

Google this year rejected an abortion clinic’s ads on similar grounds.

That clinic is Carafem, one of the D.C. area’s newest abortion centers. The clinic has made a name for itself as a “spa-like” facility because of its wood floors reminiscent of high-end salons and the tea and bathrobes given to clients as they prepare for their abortions.

“There’s a myth that abortions are provided in lonely and frightening places,” Melissa Grant, Carafem vice president, told RH Reality Check. “Visiting a physician’s office produces a lot of anxiety with people. We are intensely aware of that.”

That unabashed approach to providing abortion services extends well beyond its interior design to its advertising, which Grant says is a crucial aspect of the clinic’s larger mission to break down the silence and taboo surrounding the procedure.

“There’s a lot to overcome related to anxiety and stigma,” Grant told RH Reality Check. “Speaking unapologetically that we provide abortion in our advertising was a key part of that goal.”

Carafem’s ads certainly are frank. Plastered in subway stations and bus stops across the D.C. area, the ads all read, “Abortion. Yeah, we do that,” over a bright pink background and the text, “Here for you. Always. 24/7.”

Those ads were also submitted to Google Display, which runs video and display ads on third-party sites as well as on YouTube, Google Search, and AdBlade, which publishes ads on sites owned by the likes of Fox News, the Hearst Corporation, and McClatchy.

Both companies rejected Carafem’s ads, although Google ran them for two weeks before finally rejecting them, according to clinic staff. In an email to the clinic, a Google ad representative explained that abortion ads are allowed in some countries, but even then are restricted as “non-family safe” ads, meaning they will only appear in Google Search and never via Google Display.

A Google website describing the company’s health care related advertising policies lists the countries in which abortion ads are altogether barred. The United States is not one of them. Abortion is not listed as an example of “non-family safe” advertising, described by Google as including services like strip clubs, sex toys, and plastic surgery focused on genitalia.

In an email to RH Reality Check, a Google spokesperson reiterated what had been communicated to Carafem, saying that the company allows “ads for reproductive health, including information about abortion, on search ads on Google and on video ads on YouTube through direct buys. We don’t allow ads for abortion information to run on third-party publisher sites through Google Display Network.”

AdBlade did not provide comment to RH Reality Check on its ad policies.

An AdBlade spokesperson told Carafem in an email that the company wouldn’t run the ads “due to the sensitivity of the topic.”

The company’s general policies webpage lists the types of ads that are prohibited and restricted, among them, overly sexual or grotesque images, gambling and betting services, and “adult” advertisers. Neither abortion nor any other medical procedure is listed.

A reluctance to run ads mentioning abortion and other reproductive and sexual health issues is not reserved for Google and AdBlade. In 2014, four companies were barred from advertising on Twitter because their ads discussed sexual health issues.

Two of those were condom companies, one was an “online birth control support network,” and the other was an STD education organization.

Grant said that while she doesn’t consider it an act of censorship, the Carafem staff thinks it’s odd that the ads were considered too “adult” and rejected.

“Our advertising is not flippant or outlandish. The only thing that’s innovative is the way we’re talking about abortion,” she said. “We’re afraid to speak outwardly that abortion is a service, the way we talk about mammograms or whatever else. By its non-discussion, it’s called out as different. Abortion is not something to be embarrassed about. If a woman can’t see information about a basic medical procedure that she needs, there’s something wrong.”

Abortion care, a provably safe medical procedure that affects one in three women, is an unsuitable topic for millions of people worldwide, according to Google and Hulu, which recently rejected informational advertisements that discuss abortion.

Abortion care, a provably safe medical procedure that affects one in three women, is an unsuitable topic for millions of people worldwide, according to Google and Hulu, which recently rejected informational advertisements that discuss abortion.

“Let’s pretend that life is perfect and everything happens exactly as you plan,” says the narrator of a video ad, produced by Productive Rights and paid for by UltraViolet, which uses petitions and ads to address progressive political issues. “You go on a date with the guy of your dreams. Your condom never breaks. You never make mistakes and you never need to access abortion.”

“Let’s end the pretending,” the ad continues. “Condoms break. Mistakes are made. Abortion is a part of real life.”

The video is one of three submitted by UltraViolet to a handful of media platforms. The group also submitted a number of static-image ads, all of which contain messages about the importance of abortion access.

Adam Brink, campaign director for UltraViolet, told RH Reality Check that the ads were accepted by Pandora and NBC.com, as well as SiteScout and Millennial Media, two advertising companies. But Google (which owns YouTube) and Hulu rejected the ads, telling UltraViolet that the focus on abortion did not meet advertising standards.

A Google ad representative, in an email to UltraViolet, wrote that abortion is considered a “non-family safe” topic, and that all ads about the procedure are rejected for showing on Google Display Network sites, which includes YouTube.

Neither abortion care nor any other common medical procedure is listed.

The Google Display Network, which shows ads on Gmail and YouTube as well as publisher sites like NYTimes.com and to which UltraViolet submitted its proposal, “reaches 90 percent of Internet users and includes more than 2 million publisher sites,” according to Google.

UltraViolet received a similar notice from a Hulu representative, who wrote that the company doesn’t accept any ads related to abortion, whether for or against, based on its ad standards.

Though the company would not share with UltraViolet the document describing those standards, the representative wrote that abortion is not something they want to put in front of viewers.

Hulu’s webpage outlining restrictions for advertising lists a number of ad categories that are never accepted, but abortion is not one of them. Included in the list of topics never advertised by Hulu is porn, escort services, illegal activities, and sex toys.

“They’ll air ads about Viagra but not about a common and constitutionally protected women’s health procedure,” he continued. “It’s this kind of attitude that promotes silence.”

Both Google and Hulu have come under fire for their ad policies related to abortion. Last October, Hulu caught flack for refusing to run an ad decrying Colorado’s radically anti-choice Amendment 67.

Google caught the attention of abortion access activists after NARAL Pro-Choice America found that the company had allowed ads from crisis pregnancy centers claiming they offered medical services such as abortion, though they do not.

Google eventually removed the ads based on the standard that ads be “factually supportable,” according to the Washington Post.

Other media platforms have similarly received criticism for censoring ads related to abortion and other reproductive health issues. Four companies in 2014 were barred from advertising on Twitter because their ads discuss sexual health issues. Two are condom companies, one is an “online birth control support network,” and the other is an STD education organization.

Though not an advertisement, Instagram recently removed the photo of a woman with a period stain on her pants, saying that it didn’t follow the sites “community guidelines.” The company apologized for removing the picture after receiving a flurry of online criticism.

UltraViolet, since having its ads rejected, has created a petition asking both companies to reverse their decisions.

Sex and sensual images have been used for years in developed countries to sell everything from beer and soft drinks to cars and hotels, yet in reproductive health we have shied away from doing this even though much of our work is aimed specifically at people who are having, or contemplating, sexual relations.

Can the promise of a better orgasm, or at least a fear-free sexual experience, improve the chances that couples will use family planning? If a couple is not afraid of getting pregnant or picking up a sexually-transmitted infection, will they enjoy the sexual experience more? And if they do, shouldn’t the reproductive health and family planning community capitalize on that and apply the lessons learned by the multitude of marketers who know that sex sells?

I realize that the idea is scary for those who worry that such strategies will promote sex. It is safer to keep family planning and reproductive health medicalized, sanitized and respectable.

But the last time I checked, young people did not call their friends to talk about their “reproductive health” or “contraceptive options.” They talk about their sex lives — and they talk about it a lot! More and better use of language, imagery and presentation of a sensual and even erotic nature will go a long way towards making family planning more desirable, even fashionable, especially among young people who are increasingly sophisticated in terms of marketing.

Perhaps most importantly, people use products because of imagery and the aspirational qualities associated with it. I believe that if we start using the same tactics that have proven effective with other consumer goods to market products that are, in fact, all about relationships, love and sex, we will increase demand for these products.﻿

A couple of examples:

For obvious reasons, condoms are a product easily promoted with sensual imagery, a fact that is now generally accepted by the reproductive health community. In Brazil and the Philippines, DKT International is using sexy imagery to sensualize and promote condom use. In the Philippines, DKT has promoted Premiere condoms in partnership with For Him Magazine, while in Brazil, steamy TV commercials and a sexologist blog combine erotica with practical advice promoting safety.

In Africa as well, condom programming has evolved. In Malawi, Chisango (which means “shield” in the local language) was launched in 1994 as part of an HIV prevention program, with a brand featuring a silhouetted image of a demure couple with a Zulu shield. It was a conservative brand for a conservative country. But by the mid-2000s, condom use among young men (one of the prime target groups of Chisango) was waning and research showed they rejected this now outdated brand, calling it “my father’s condom.” A new, more provocative brand was developed — a photo of a sexy woman from the waist down, revealing a shapely leg bared by a slit in her dress. The image set off a bit of a firestorm. The National Censorship Board declared the image “obscene” and it had to be taken off outdoor billboards. But it was allowed to remain on the package and in other advertising and promotion. The negative publicity actually helped sales.

Use of erotic imagery to promote family planning (as opposed to HIV prevention) has been less the norm but this need not be the case. In Indonesia, DKT International has used sensual images of a couple on a bed, legs entwined, to promote emergency contraception. Also in Indonesia, DKT has used the promise of a better sexual experience to promote intrauterine devices, counseling men in ads that IUDs do not take away any pleasure from intimacy.

Those of us in global health need to be willing to meet consumers closer to where they are living, thinking and having sex when we promote family planning and reproductive health.

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Across the country, women have
heard that Sarah Palin forces rape victims to pay for their rape kits,
that Barack Obama supports infanticide, that McCain will do everything
in his power to constitutionally ban abortion, and more. Of course,
not all of these allegations are true. But as the election hits
the home stretch, ads targeting the candidates’ positions on reproductive health are
blaring from radios, televisions and computer screens, regardless of their accuracy. The
ads are popular in swing states, where issues like choice and the future
of Roe could net the dueling presidential candidates some crucial voters.

The following is a round-up
of some of the best, and worst, ads voters are watching and listening to
as the election draws near.

The Final Round

After the final presidential
debate, NARAL seized on John McCain’s widely-discussed
use of "air-quotes" and a dismissive tone around the notion of a woman’s health exception to a late-term abortion ban. NARAL created this starkly compelling ad.

The Verdict: Okay, so McCain
didn’t use the air quotes ten times in a row. But even using
them once reveals a disturbing lack of sympathy for the health issues
facing women in all circumstances, as well as this particular one.

Another viral video that
has been circulating on the Internet in recent days features a young
woman, tearily addressing VP Candidate Sarah Palin: "I didn’t have
a choice about being raped, but I should have a choice about this,"
she says, referring to Palin’s opposition to abortion even in cases of rape or incest. The ad was created by a group called "Women Against McCain
Palin."

The Verdict: It is unclear
whether the woman in the ad is a real rape victim or an actress, but
the website does feature testimonials from rape victims, as well
as a number of sourced articles addressing Sarah Palin’s position
on abortions for victims of rape and incest.

Rape Kits

The news spread quickly last
month that under Sarah Palin’s mayoral administration, survivors of rape in Wasilla,
Alaska, had to pay out of
pocket for their own rape kits. The public outcry prompted several ads.

The Nurses Association of California,
an 85-thousand member union, released an ad warning voters about Sarah
Palin, set to a chorus of "One Heartbeat," — reminding viewers that vice-presidential candidates are not presidential
candidates’ political assistants, but their potential successors.
As the tune plays, the ad mentions Palin’s rape kit policy as the
very first among a group of troubling laws and policies that Palin supported as mayor.
The ad ran in Ohio, Wisconsin, Michigan, Minnesota, Colorado, and Missouri.

Verdict: The charges
leveled against Palin in this ad tend to be more sensationalistic, and
less based on her actual policies as mayor (e.g. she did apparently
once ask a librarian about book banning, but never outright banned books).
The rape kit policy was, however, part of a budget that
Palin explicitly signed off on.

Planned Parenthood also targeted
the rape kit issue in an ad. The ad mentions not only Palin’s policies
as mayor, but also McCain’s similar votes on the issue in the Senate.
The Planned Parenthood ad is bookended by an interview with a rape survivor,
Gretchen, who says of making victims pay for their kits: "That is
something unthinkable, it scares me to death." The intense first person
interview takes the focus back to the individual women who are affected.

Verdict: Despite the
emotional tenor of this ad, it comes with a detailed factual citation
both within the ad itself and on the website site, including basic list
of citations and a detailed PDF line-by-line explanation. You can find more information
about the Wasilla rape kit controversy is here.

On The Radio — Obama on
Roe, Republicans for Choice

Last month, Obama released
a series of radio ads in swing states that featured a clip of John McCain,
during an interview on Meet The Press, saying he favored a constitutional
amendment banning all abortions. The radio spot is narrated by a nurse,
who says that if that happens, "the lives and health of women will
be put at risk." The radio ad garnered some attention because it seemed
to indicate that the Obama campaign sees choice as a winning
issue among undecided voters, rather than the third rail that many media
figures portray it as.

Verdict: While it’s
unclear whether McCain would aggressively pursue a constitutional abortion
ban as president, there is absolutely no question that the new Supreme
Court nominations under a McCain presidency would put Roe in serious
jeopardy, as he’s cited
Roberts and Alito
as the model for judges he would pick.

Meanwhile in Colorado, where
a ballot initiative declaring a fertilized egg a person is causing
serious alarm for women’s rights advocates, a group of Republicans,
The Republican Majority for Choice, has put out a strong radio ad encouraging
voters to vote "No." The spot is a dialogue between a husband and
wife. The husband says: "I want the government focused on the major
issues facing our state and our country – NOT in the middle of our personal
medical choices." (Transcript here.)

Verdict: The ad provides
a straightforward explanation for what would happen if a fertilized
egg had legal rights: "basic birth control" might be outlawed, and
the state would face many costly lawsuits from families and doctors.

Catholics Split

The group CatholicsUnited.com has run an ad in crucial swing state markets with Catholic populations.The ad features a Catholic mother sitting at her kitchen table–the
most popular place in the house this political season–pointing out
that the moniker "pro-life" applies to more than one issue. She
says John McCain’s record on health care and the war is not consistent
with that moniker.

Verdict: On the site’s
home page (catholics-united.org) the group cites McCain’s votes
against SCHIP and his support of the Iraq war as the factual backup
for this ad, as well as mentioning studies that show that the legality
of abortion has little effect on the abortion rate-while health care
and economic issues do affect the abortion rate.

On the other hand, the groupCatholicVote.com has a viral video (not an ad), that sends the exact
opposite message. Set to stirring music, writing onscreen reminds voters
that "some issues"–over a picture of a fetus–"are more important
than others"–backgrounded by a gas pump. The ad focuses on the importance
of "life and the family"–and images of anti-choice rallies and
gay marriage make it clear what that phrase means.

Verdict: The ad is mostly
abstract and makes no factual claims. But the reality is that voting
primarily on abortion may not have as wide effect on the abortion rate
so much as voting on access to health care, birth control
and sexuality education will.

The Ugly

As the race gets dirtier,a group of anti-choicers are preparing a radio ad that would bring
back the old infanticide rumors against Barack Obama. And this ad, sponsored
by the National Right to Life committee gets personal, engaging Obama
in a he-said, she-said (or a he-lied, she-lied) spat.

Verdict: The timeline of this
issue is thorny and there have been mis-statements on both sides, but
Obama’s position on the "Born Alive" acts was definitively not
extremist, as many on the opposing side allege. Existing law protected infants already; the Senator was acting,
as he has said, to protect Roe and physicians from liability.
For a detailed investigation of both side’s claims, this article by
Eric Zorn in the Chicago Tribune
is about as thorough as possible.

A ballot initiative in
California that would mandate parental notification for teens seeking abortion plays into parents’ worst fears. The ad features a grimy
actor playing a "child predator"–a man who serially impregnates
teen girls and takes them to get abortions–saying that he likes the
law as it is because it keeps his behavior "secret." The ad is low
quality, but certainly does have a creepy effect.

Even after the president is
elected, damaging rumors and false assertions about crucial reproductive health issues will
linger thanks to some of these ads, while the facts will do their best
to shine through thanks to the efforts of others.